MECKEL'S DIVERTICULUM: ITS CLINICAL SIGNIFICANCE—A Report of 54 Cases

Of 54 cases of Meckel''s diverticulum observed at one hospital in a 20-year period, 27 were noted incidentally and 27 caused symptoms. In the latter group, the patients were preponderantly males. The most common symptoms, in order of frequency, were hemorrhage from the bowel, intestinal obstruction, acute diverticulitis, and intussusception. All the complications except intestinal obstruction occurred in infancy and childhood more often than in later life. Intestinal obstruction was limited to adults. There was strong coincidence of complications and ectopic tissue. Surgical excision was done in all cases of diverticulum causing symptoms, and all patients recovered.     

Childhood deaths from intussusception in England and Wales, 1984-9.

OBJECTIVE--To assess the incidence of potentially avoidable factors contributing to death of children with intussusception. DESIGN--Review of children who died with intussusception in England and Wales between 1984 and 1989 from data of the Office of Population Censuses and Surveys, case notes, coroners'' records, and necropsy reports. MAIN OUTCOME MEASURES--Unambiguous objective criteria such as failure to diagnose intussusception within 24 hours of admission. RESULTS--33 children died of acute intussusception in England and Wales between 1984 and 1989 compared with 67 in the previous six years. Their median age was 7 months (range 2 months to 12 years), and two thirds were boys. Half of the deaths occurred at home or soon after arrival at hospital but 15 patients had surgery. Potentially avoidable factors contributing to death were identified in 20 (61%) children, all but three of whom had ileocolic intussusception. These factors were excessive delay in diagnosis, inadequate intravenous fluid and antibiotic therapy, delay in recognising recurrent or residual intussusception after hydrostatic reduction, and surgical complications. Of the 13 patients in whom no avoidable factors were identified, there were nine of 11 children with isolated small bowel intussusception, who tended to have atypical presentations. CONCLUSION--Although the mortality from intussusception has declined, there remains ample opportunity for improved management.     

Barium reduction of intussusception in infancy

Barium enema reduction was used as the initial routine treatment in 29 infants with intussusception. In 22 of them the intussusception was reduced by this means. In three of eight patients operated upon the intussusception was found to be reduced. Four of the remaining five patients had clinical or x-ray evidence of complications before reduction by barium enema was attempted.Twenty-one of the patients, all of whom were observed in private practice, were treated without admission to the hospital. After reduction, these patients were observed closely by the clinician. None of these patients showed clinical or x-ray signs of complications before reduction. Certain clinical and roentgen criteria must be satisfied before it can be concluded that reduction by barium enema is complete. If there are clinical signs of complications with x-ray evidence of small bowel obstruction, only a very cautious attempt at hydrostatic reduction should be made. As the time factor is generally a reliable clinical guide to reducibility, the late cases should be viewed with greater caution. Long duration of symptoms, however, is not per se a contraindication to an attempt at hydrostatic reduction.     

Colposcopy in a family planning clinic: a future model?

The first year''s experience of a satellite colposcopy clinic in the Glasgow Family Planning Centre was analysed. Establishment of the clinic was supervised by an experienced member of the colposcopy team at the department of gynaecology, Western Infirmary, Glasgow, who trained one of the family planning centre''s staff. Close links were thus maintained with the hospital clinic to which patients were referred for treatment. The policy at the new colposcopy clinic was to study prospectively all women in the hospital catchment area whose cervical smears were reported as abnormal. In 58 of 162 such patients there was at least moderate dyskaryosis and the cytologist''s recommendation had been referral for colposcopy. In 104 cases the changes were either atypia alone or mild dyskaryosis and a repeat smear was recommended within three to 12 months; 18 of these patients had grade II or III cervical intraepithelial neoplasia on biopsy, and relying on repeat smears would have resulted in an 11.7% false negative rate. If an atypical cytological picture is to be an indication for colposcopy clinics attached to family planning centres may have an important role, given satisfactory training and close links with central specialist colposcopy clinics.     

Meckel's diverticulum: its clinical significance; a report of 54 cases

Of 54 cases of Meckel's diverticulum observed at one hospital in a 20-year period, 27 were noted incidentally and 27 caused symptoms. In the latter group, the patients were preponderantly males. The most common symptoms, in order of frequency, were hemorrhage from the bowel, intestinal obstruction, acute diverticulitis, and intussusception. All the complications except intestinal obstruction occurred in infancy and childhood more often than in later life. Intestinal obstruction was limited to adults. There was strong coincidence of complications and ectopic tissue. Surgical excision was done in all cases of diverticulum causing symptoms, and all patients recovered.     

Legionnaires' disease caused by Legionella dumoffii in distilled water.

Five cases of Legionnaires'' disease caused by Legionella dumoffii were identified within an 11-month period in a hospital in the Quebec City area. In four cases bacterial isolates were obtained from clinical specimens, and in one case seroconversion was demonstrated. All the patients had been admitted to hospital within 10 days before diagnosis. Two of the patients were immunosuppressed children. Only 1 of the 40 hot water samples from the hospital yielded L. dumoffii; however, 6 of 11 distilled water samples contained the bacterium. All the patients had been exposed to distilled water, four through respiratory therapy equipment and one through a room humidifier. Following the use of sterile distilled water in the apparatus, no further cases were identified. This is the first reported outbreak of Legionnaires'' disease caused by L. dumoffii, and it is the first time that nosocomial legionellosis has been linked to contaminated distilled water in Canada.     

Cardiac Manifestations During a Coxsackie B5 Epidemic

During a widespread Coxsackie B5 epidemic which occurred in Finland in the autumn of 1965 18 patients with acute myopericarditis were admitted to Kuopio Central Hospital (530 beds, representing a hospital district with 270,000 inhabitants) within a period of three months.The mean age of these patients was 28 years. Twelve were males and six were females.In 12 cases Coxsackie B5 virus and in one case Coxsackie A9 virus were isolated from the faeces. A significant increase in neutralizing antibodies or high antibody titres (≥1:128) were noted in 16 cases against Coxsackie B5 and in one case against Coxsackie A9. In two cases the cause of the myopericarditis remained obscure.All the patients had fever. Six showed all classical criteria of pericarditis: chest pain, pericardial rub, E.C.G. changes, and radiologically observable enlargement of the heart. As regards the various criteria, E.C.G. changes were found in all cases. Signs of cardiac tamponade were observed in one patient. Five, in addition, showed aseptic meningitis.All the patients recovered. Twelve were re-examined at an average of seven months after discharge from hospital. All were symptom-free except one, who still showed E.C.G. changes.     

MENINGITIS—A Review of One Year's Cases from an Active Children's Hospital Service

Fifty-six cases of bacterial meningitides, other than tuberculous, observed in a period of one year on an active children''s hospital medical service were reviewed. All age groups were involved but most commonly infected were patients in the first year of life. There was no inordinate incidence of infection with any one kind of organism in any specific age bracket, except possibly for infection with enteric organisms which in the present series occurred preponderantly in infants less than six months old. Meningococcus and H. influenza type B were the most common organisms; they were the infecting agents in 71 per cent of cases. Of the immediate complications noted, subdural effusions were the most common (23 per cent of this series). In all except two cases, effusion was resolved by multiple aspirations. In two cases craniotomy was done with good results. Ten electroencephalograms were made and all were abnormal. In most of the patients, multiple antibiotic and chemotherapeutic drugs were used, parenterally during the first few days of hospitalization and then orally as tolerated. Intraspinal therapy was not given. Four of the 56 patients died.     

Gastrointestinal complications of renal transplantation. 2. The colon.

In 95 consecutive cases of cadaveric renal transplantation followed up for 1 to 83 months (mean 23.1 months) seven colonic complications developed in seven patients; these included ischemic colitis in three, colonic perforation in two, fecal impaction in one and appendicitis in one. Except for appendicitis all the complications occurred within 2.5 months of transplantation and were not related to the patient''s age, sex, blood group, or use of cigarettes or alcohol, the duration of hemodialysis before transplantation, the tissue match or the number of infusions of immunosuppressive medication. Two patients died, but not of the complication. In the management of free colonic perforation prompt resection or exteriorization, with avoidance of intraperitoneal suture lines, and continuous postoperative peritoneal lavage may be lifesaving. Early surgical intervention and creation of a colostomy in one of the cases of ischemic colitis proved helpful.     

Curative Radiotherapy in Hodgkin's Disease: Significance of Haematogenous Dissemination Established by Examination of Peripheral Blood and Spleen

Studies of peripheral blood leucocyte concentrates in patients with Hodgkin''s disease showed two types of cells believed to be typical for the disease in a number of patients. Involvement of the spleen as diagnosed after splenectomy and histological examination showed a close correlation with the presence of these characteristic cells in the peripheral blood. This is believed to be an argument for haematogenous spread or a multicentric origin of the disease in these cases. The results of attempted curative high-voltage radiotherapy with total node irradiation in 24 patients seem to support this concept. On the basis of the Rye classification of clinical stages the results of radiotherapy are not predictable. Six patients in stage II and seven in stage III were in remission, one in each of stages II and IV, and six in stage III had recurrences of the disease within one year. A division into localized or disseminated forms of the disease based on the investigations of blood and spleen showed all localized cases in remission; of the disseminated cases one reached a remission and all others had recurrences. In three patients the therapy could not be completed. These preliminary treatment results are believed to support the idea of a special role of the spleen in the dissemination of the disease. A new classification of clinical stages in Hodgkin''s disease is proposed.     

Interim discharge summaries: how are they best delivered to general practitioners?

All patients discharged from a medical ward during four months were randomly assigned to one of two groups. In one group the patients were given their interim discharge summary for delivery to their general practitioner by hand; in the other group the summary was posted by the hospital. Of the 289 summaries sent by either method, 279 (97%) arrived at the general practitioner''s surgery. A mean (median) time of two (one) days elapsed before arrival when summaries were delivered by hand and a mean (median) of four and a half (four) days when they were posted; at least 55% of summaries delivered by hand arrived within one day of the day of discharge compared with 8% of those posted. If all interim discharge summaries were given to patients to deliver communication between hospitals and general practitioners would be accelerated and considerable savings might be made.     

General practitioner response to elderly patients discharged from hospital.

OBJECTIVE--To determine the effect of discharge information given to general practitioners on their management of newly discharged elderly patients. DESIGN--A random sample of 133 elderly patients who had unplanned readmission to a district general hospital within 28 days of discharge was compared with a matched control sample of patients who were not readmitted. Information was gathered from the hospital, the patients, the carers, and the general practitioners about the information that the hospital had sent the general practitioner and the general practitioners'' response to this information. SETTING--All specialties in a district general hospital. PATIENTS--266 Patients aged over 65 representative in the main demographic indices of the population of elderly patients admitted to hospital. RESULTS--Ten weeks after discharge the doctors had received notice of discharge about 169 of the patients, but fewer than half the discharge notices were received within the first week. General practitioners were dissatisfied with the information in 60 cases. A general practitioner visited 174 of the patients after their discharge from hospital and three quarters of the visits took place within two weeks of the discharge. These visits were more likely to have been initiated by patients or families than by the doctor, and this was not influenced by the doctor receiving notice of the patient''s discharge. Older patients and those who had carers were the most likely to be visited. Nearly half of the carers were dissatisfied with some aspect of general practitioner care, problems with home visiting being the commonest source of complaint. CONCLUSIONS--Hospital communications to general practitioners about the discharge of elderly patients still cause concern, particularly in the time they take to arrive. Written instruction to vulnerable elderly patients asking them to inform their general practitioner of the discharge might be helpful. Carers complained of lack of support, and it is clearly important for someone (either the general practitioner or another health worker) to visit elderly people shortly after their discharge.     

Patient and general practitioner delays in acute myocardial infarction

The longest component of the total delay in coming under coronary care is patient delay, and it has been suggested that public education might be used to make it shorter. The patterns of patient delay were studied in 450 patients with acute myocardial infarction uncomplicated by cardiac arrest out of hospital, of whom 243 had a previous history of ischaemic heart disease. Patient delays had a skewed distribution with a modal delay of up to one hour, a median delay of two hours, and a mean delay of 10 hours. Two thirds of patients had sought help from their general practitioners within four hours of the onset of symptoms. During the first four hours the longer that patients delayed the lower was the subsequent mortality (27%, 18%, and 9% for delays of one hour or less, up to two hours, and up to four hours, respectively), but patients who delayed four to eight hours had the highest mortality of all (38%). Neither the median value nor the pattern of patient delays was altered by a previous history of ischaemic heart disease.There were pronounced differences in doctor delays, depending on the patient''s age, delay time, and ultimate place of treatment, showing that the doctors'' behaviour was influenced before they had seen their patients. Nevertheless, the median total delay for patients aged up to 70 was one hour 35 minutes, and a higher proportion of patients were seen early after infarction than in recent hospital trials of thrombolytic treatment.These findings suggest that the patients'' call for help and the doctors'' response may be at an instinctive level according to the patients'' distress; these patterns of behaviour may be difficult to modify by public education.     

Clinical and Diagnostic Significance of Enteroclysis Through Nasointestinal Decompression Intubation

To study the clinical and diagnostic significance of enteroclysis through nasointestinal decompression intubation, thirty-five patients with small bowel obstruction were enrolled. A nasointestinal catheter of 300 cm was placed through the nasal cavity then pushed to the upper jejunum under X-ray realtime monitoring. The patients underwent intra-small-intestinal suction therapy reducing or relieving the obstruction after 3 days. As the catheter reached the lesions, we conducted selective imaging. Using fluoroscopy, we injected 20–100 ml meglumine diatrizoate 76 % and 50–200 ml air via the decompression suction port to produce a double-contrast radiography. The catheter was then retrieved to the upper jejunum, and the X-ray of the small intestine was obtained. All 35 patients had successful intubations. The decompression treatment resolved symptoms in 20 cases and alleviated symptoms in 15 cases. Ten cases underwent surgery. The images obtained by infusing meglumine diatrizoate through the decompression catheter were of good quality. Among the 35 cases, six were absent of any distinct abnormal signs on the X-ray, 15 had adhesive ileus, four had small bowel tumor (three metastatic tumor, one small bowel cancer), three had Crohn’s disease, three had radiation enteritis (one of the three was mistaken for small bowel metastatic tumor), two had enteric intussusception, one had a polyp in the small intestine, one had ascending colon cancer. The nasointestinal decompression intubation under X-ray monitoring serves a dual function for patients with intestine obstruction, by decompressing the small bowel and examining the small intestinal radiographically. The X-rays can confirm the obstruction and provide guidelines for surgery.     

Terminal cancer care and patients' preference for place of death: a prospective study.

OBJECTIVE--To assess the preference of terminally ill patients with cancer for their place of final care. DESIGN--Prospective study of randomly selected patients with cancer from hospital and the community who were expected to die within a year. Patients expected to live less than two months were interviewed at two week intervals; otherwise patients were interviewed monthly. Their main carer was interviewed three months after the patient''s death. SETTING--District general hospital, hospices, and patients'' homes. MAIN OUTCOME MEASURE--Stated preferred place of final care; actual place of death; reason for final hospital admission for those in hospital; community care provision required for home care. RESULTS--Of 98 patients approached, 84 (86%) agreed to be interviewed, of whom 70 (83%) died during the study and 59 (84%) stated a preferred place of final care: 34 (58%) wished to die at home given existing circumstances, 12 (20%) in hospital, 12 (20%) in a hospice, and one (2%) elsewhere. Their own home was the preferred place of care for 17 (94%) of the patients who died there, whereas of the 32 patients who died in hospital 22 (69%) had stated a preference to die elsewhere. Had circumstances been more favourable 67% (41) of patients would have preferred to die at home, 16% (10) in hospital, and 15% (9) in hospice. CONCLUSION--With a limited increase in community care 50% more patients with cancer could be supported to die at home, as they and their carers would prefer.     

Towards a more rapid diagnosis of rapidly progressive glomerulonephritis.

An attempt was made to provide simple practical guidelines to alert general practitioners to the diagnosis of rapidly progressive glomerulonephritis and lead to early referral to hospital. The duration of illness before referral to this hospital and its effect on outcome in patients with crescentic nephritis were assessed retrospectively from the case notes of 24 patients referred over two years. Four patients had Goodpasture''s syndrome, 11 Wegener''s granulomatosis, seven microscopic polyarteritis, and two idiopathic progressive glomerulonephritis. The duration of symptoms before referral to the local hospital was similar in the four groups of patients and varied from one week to 28 months (mean 10 months). The duration of stay in the local hospital was two, nine, 11, and 180 days in the patients with Goodpasture''s syndrome and a mean of four days (range one to eight) in those with Wegener''s granulomatosis and 10 days (one to 18 days) in those with microscopic polyarteritis. In the local hospital the diagnosis was based on the results of renal biopsy and detection of antibodies to glomerular basement membrane in two patients with Goodpasture''s syndrome and on the results of renal biopsy in seven of the other patients aided by the detection of antibodies to the cytoplasm of neutrophils (ANCA) in 10. Three of the 24 patients died and four required maintenance haemodialysis. Patients who present to their general practitioners with persistent non-specific symptoms should have a urine dipstick test and then blood tests and emergency referral to hospital if necessary. Hospital physicians should be aware of the speed and accuracy with which current assays can confirm a diagnosis of rapidly progressive glomerulonephritis.     

Major disaster planning.

In 1983 a coach crash brought a hospital''s major disaster plan into operation. The surgical aspects of the plan were assessed to see how well they matched up to three major aims: saving life, relieving pain and distress, and completing primary treatment of open wounds within eight hours of the accident. The last goal was not met for most of the 21 victims, mainly children with multiple deep dirty abrasions and extensive tissue loss. Having determined that none of the victims were in immediate danger the surgeons reassessed the priorities--in several cases disturbing dressings for a third or fourth time. The total time spent in theatre (in five theatres) was 37 hours, as opposed to the original estimated 10-15 hours. The experience gained in this accident suggests that a disaster plan should indicate the number of patients a single hospital can admit and that a senior surgeon should act as a coordinator and get surgeons working as soon as patients arrive, keeping two theatres reserved for lifesaving surgery. In this way primary treatment of wounds may be completed within eight hours of injury and the risk of infection reduced.     

Quality improvement report: Safety and efficacy of nurse initiated thrombolysis in patients with acute myocardial infarction

ProblemDelay in starting thrombolytic treatment in patients arriving at hospital with chest pain who are diagnosed as having acute myocardial infarction.DesignAudit of “door to needle times” for patients presenting with chest pain and an electrocardiogram on admission that confirmed acute myocardial infarction. A one year period in each of three phases of development was studied.

Background and setting

The goal of the national service framework for coronary heart disease is that by April 2002, 75% of eligible patients should receive thrombolysis within 30 minutes of arriving at hospital. A district general hospital introduced a strategy to improve door to needle times. In phase 1 (1989-95), patients with suspected acute myocardial infarction, referred by general practitioners, were assessed in the coronary care unit; all other patients were seen first in the accident and emergency department. In phase 2 (1995-7), all patients with suspected acute myocardial infarction were transferred directly to a fast track area within the coronary care unit, where nurses assess patients and doctors started treatment.

Key measures for improvement

Median door to needle time in phase 1 of 45 minutes (range 5-300 minutes), with 38% of patients treated within 30 minutes. Median door to needle time in phase 2 of 40 minutes (range 5-180 minutes), with 47% treated within 30 minutes

Strategies for change

In phase 3 (1997-2001), all patients with suspected acute myocardial infarction were transferred directly to the fast track area and assessed by a “coronary care thrombolysis nurse.” If electrocardiography confirmed the diagnosis of acute myocardial infarction, the nurse could initiate thrombolytic therapy (subject to guidelines and exclusions determined by the consultant cardiologists).

Effects of change

Median door to needle time in phase 3 of 15 minutes (range 5-70 minutes), with 80% of patients treated within 30 minutes. Systematic clinical review showed no cases in which a nurse initiated inappropriate thrombolysis.

Lessons learnt

Thrombolysis started by nurses is safe and effective in patients with acute myocardial infarction. It may provide a way by which the national service framework''s targets for door to needle times can be achieved.     

Donation of kidneys. Medical Services Study Group of the Royal College of Physicians.

A survey of deaths from medical causes among hospital inpatients aged under 50 years in three health regions provided details of 1168 such deaths not caused by renal failure. Kidneys for transplantation were obtained from only 20 of these patients. In another 18 cases permission was refused or donation was impracticable. Ninety-eight of the deaths were due to subarachnoid haemorrhage and 38 to primary cerebral tumour, yet kidneys were obtained from only 11 and one of these patients respectively. Patients dying from subarachnoid haemorrhage are particularly suitable for donating their kidneys, but there is still a shortage of kidneys for transplantation because they are not harvested efficiently. Doctors seem to be reluctant to ask relatives'' permission to remove kidneys, and the arrangement of a donation is time consuming. Because transplant surgery is recognised as a specialist sphere, surgeons in other specialties may be reluctant to remove kidneys and come to rely on one transplant team covering a wide area. In an area such as Grampian, where a small population is served by one hospital containing all the major units, including accident and emergency and renal departments, it may be easier to arrange prompt donation and transplantation.